WHY IS MY SCROTUM LEAKING, DOCTOR?By Ashish Vaska, Rebecca Paxton and Laura Germein Med IV
Case Study
61yo male farmer from Eyre Peninsula Previously fit and well
Initial presentation
2/8/11 Patient underwent surgery for debridement
and drainage of a left scrotal wall abscess Wound on scrotum was loosely closed to
allow drainage Patient was discharged on flucloxacillin with
GP to remove sutures
Investigations
Histology: hidradenitis suppurativa Cultures: negative
5 weeks later...
Patient represented to surgical outpatients
Complaint of smelly discharge from scrotal wound Discharge was watery Pt noticed increased in discharge when he
was out drinking
Urgent urethrogram ordered
Urethrogram
Report
Disrupted urethra at base of penis with contrast extravasation into scrotum and out wound
No flow into bladder
Patient has no history of trauma
Anterior Urethral Disruption
Anatomy
A- Fossa navicularisB- Penile urethraC- Bulbar UrethraD- Membranous UrethraE- Prostatic Urethra
Causes
Pelvic Fractures MVAs Occupational accidents Falls from large height
Gunshot wound Iatrogenic Urethral catheters Tumour Sexual excess Penile fractures
Signs/Symptoms
Classic Triad (absence doesn’t exclude) Blood at urethral meatus Inability to pass urine Distended bladder
Others Superiorly displaced and ‘ballottable’
prostate on PR Perineal haematoma Failure to pass urinary catheter
Epidemiology
Pelvic fractures 10% of all have urethral disruption 25% if men with pelvic fractures have
urethral disruption 5% of women
Posterior disruptions are associated with complex trauma, penetrating, iatrogenic
Anterior ruptures dt penetrating injuries, instumentation, blunt
Anterior Urethral
Investigation
Retrograde urethrography
Classification of Urethral Injuries I Posterior urethra stretched but intact II Tear of the prostatomembranous urethra
above the urogenital diaphragm III Partial or complete tear of both anterior and
posterior urethra with disruption of the urogenital
diaphragm IV Bladder injury extending into the urethra IVa Injury of the bladder base with periurethral
extravasation simulating posterior urethral injury V Partial or complete pure anterior urethral
injury
Management
Acute Management
Patient Resusitation Suprapubic catheter
Palpate distended bladder or Ultrasound guidance
Conservative Management
Manage all patients with conservative therapy for 6-12wks
Catheterise- grade 1 or 2
Repeat urethrogram
Surgical Management
Endoscopic incision of stricture Formal urethral reconstruction Immediate urethral repair if:
If injury is complete penetrating or open. Repaired with fine suture material and over closure or corpus spongiosum
Complications- erectile dyfunction (50-82% dt to mech of injury, more in post disruption), recurrent stenosis (5-15%), incontinence (<4%)
Immediate Management
On consultation with urology registrar Suprapubic catheter inserted Patient discharged back to Eyre Peninsula
with weekly GP review Repeat urethrogram in 6/52 to check
healing and plan further management
References
Myers JB, McAninch JW. Management of posterior urethral disruption injuries.
Uptodate- blunt genitourinary trauma Textbook- MD consult- Consesus on genitourinary trauma,
urethral trauma
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